Healthcare Provider Details

I. General information

NPI: 1912598046
Provider Name (Legal Business Name): EMDR & SOMATIC PSYCHOTHERAPIES OF RHODE ISLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RICHMOND SQ STE 333C
PROVIDENCE RI
02906-5139
US

IV. Provider business mailing address

PO BOX 5
KINGSTON RI
02881-0005
US

V. Phone/Fax

Practice location:
  • Phone: 401-441-5834
  • Fax: 401-210-8248
Mailing address:
  • Phone: 401-441-5834
  • Fax: 401-210-8248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. MADRONE PHOENIX
Title or Position: OWNER
Credential: LICSW
Phone: 401-297-0692